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HomeMy WebLinkAboutNCC233710_FRO Submitted_20231215 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name Brevard Staytion 2. Location of land-disturbing activity: County Transylvania City or Township Brevard Asheville Hwy Highway/Street Y Latitude(deci 35.263764 ma,degrees) Li 82.715565 ong tude(decimai degrees) 3. Approximate date land-disturbing activity will commence: October 15, 2023 4. Purpose of development(residential, commercial, industrial, institutional,etc.):Commericial 5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 3.95 6. Amount of fee enclosed $1400 . The Express Permitting application fee is a dual charge. The normal fee of$100.00 per acre(rounded up to the next acre)is assessed without a ceiling amount. In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express Permitting supplemental fee is a fixed$2,000.00 (Example:8.10-acre application fee is$2,900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Josh Shober E-mail Addressjosh@wheelhousebuilders.com Phone: Office# (828) 577-5493 Mobile# (828) 577-3820 9. Landowner(s)of Record (attach accompanied page to list additional owners): Pisgah Hospitality, LLC Name Phone: Office# Mobile# 2626 Glenwood Ave Ste 550 2626 Glenwood Ave Ste 550 Current Mailing Address Current Street Address Raleigh, NC 27608 Raleigh, NC 27608 City State Zip City State Zip 10. Deed Book No. 1 050 Page No. 1 51 -153 Provide a copy of the most current deed. Part B. 1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies). Pisgah Hospitality, LLC bjb.sc.usa@gmail.com Company Name E-mail Address 2626 Glenwood Ave Ste 550 2626 Glenwood Ave Ste 550 Current Mailing Address Current Street Address Raleigh, NC 27608 Raleigh, NC 27608 City State Zip City State Zip Phone: Office# Mobile# (864) 915-1374 Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation control plan and to conduct the anticipated land disturbing activity. 2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State business registry, give name and street address of the Registered Agent: Corporation Service Company SOP@cscglobal.com Name of Registered Agent E-mail Address 2626 Glenwood Ave Ste 550 2626 Glenwood Ave Ste 550 Current Mailing Address Current Street Address Raleigh, NC 27608 Raleigh, NC 27608 City State Zip City State Zip Phone: Office#800-927-9800 Mobile# Yvette Bronner Name of Individual to Contact(if Registered Agent is a company) (b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated North Carolina agent who is registered on the NC Secretary of State business registry: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Name of Individual to Contact(if Registered Agent is a company) (c) If the Financially Responsible Party is engaging in business under an assumed name, give name under which the company is Doing Business As. If the Financially Responsible Party is an individual, General Partnership,or other company not registered and doing business under an assumed name,attach a copy of the Certificate of Assumed Name. Company DBA Name . ... -'... cc � r-�._t¢ � [1 3_• ram. n�<.-� L._S ..MI_. },, r,..nt nt }hr. cn t n-=s. r consultant who can assist in providing any necessary information regarding the plan and its preparation: High Country Engineering, PC rncayabyab© hcepc.net Engineering firm or other consultant E-mail Address Marie Cayabyab (828) 230-4511 (971)888-1922 (ndividu�i nnnt2ct rieMnn(t'_n a nr print) Dhnn The above information is true and correct to the best of my knowledge and belief and was provided by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s) or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to execute instruments for the Financially Responsible Party). I agree to provide corrected information shoilrl there hp any change in the information provided herein- Brice J. Bay Member Tvnn or riot narnelAuthorityTitto or g131zoz-2)- i-Y _ur? Date I, 145 n b-S cc l T , a Notary Public of the County of CIt(2¢ntA l State oksVCarolina, hereby certify that 51(ICC. • appeared person Ily before me this day and being duly sworn wasacknowledged that the a ve form�� executed by nlmih r. 6 Witness my hand and notarial seal,this day 20 ot' a vcc Seal My 7mm 5520n expires 2 -